Digesting the difficult decisions of development

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It's not clear that if we all beg for bigger slices, we'll just get more pie.

Alanna Shaikh rightly points out that, despite the incredible important of funding HIV/AIDS programmes, there are many health problems that are losing out in the fundraising arms race.

But here’s what I have figured out in the last decade: we can have more pie. Differently put, global health is not a zero-sum game. We can increase the funding that goes to it. In the last ten years, we have. The Global Fund and the Gates Foundation have radically increased the resources available to global health. The private sector has started funding global health, and government donors have increased their commitments.

There is nothing wrong with so much attention going to AIDS. HIV gets exactly as much attention as it deserved. It’s the second most terrifying pandemic of our time. (I really think first place belongs to MDR TB). About two million people a year die from AIDS, and there are about 33 million people currently infected with HIV. It is devastating to communities, families, and nations. It is worthy of every red ribbon, activist, and dollar of funding it receives.

What is wrong is that other health problems don’t get as much attention. And that’s not a problem we solve by ignoring HIV. It’s a problem we solve by bringing more attention to the rest of the world’s serious health problems. We should learn from the publicity for HIV, not complain about it. What we need is to get that kind of attention for everything that deserves it.

I am a little skeptical that the answer lies with more or better publicity for neglected health problems. I think it is unlikely that we are capable of increasing the volume of campaigning on some worthy causes while somehow avoiding crowding out others by increasing the overall pie. Owen Barder does a good job of dissecting some of the issues here.

For one, the more causes that potential donors get bombarded with, the less effective any of them will be. I should demonstrate this with some resounding empirical work, but I think this video of Robert Stack fending off a bunch of activists at LAX says it all:

So increasing overall noise by amplifying fragmented messages might not increase global giving and might even fatigue the entire process.

What about crowding out? We need to be more honest about how many messages we can take on board at once – our collective time thinking about global problems is rather limited. If someone tells me I should be thinking about neglected tropical diseases, that’s less time I’ll spend thinking about HIV/AIDS or education or conditional cash transfers or international trade.

A key assumption behind the Global Burden of Disease project is that it is possible to come up with a “Disability Weight” for each health state. Diseases conditions that are considered worse than other carry higher disability weights than others. A very important issue in the development of such weights is the question of who should define these conditions? Should those who have the conditions be the best judge or are they biased? Should healthy people who have never experienced these conditions be the judge? Should doctors decide? Should policy makers? Should health economists (gasp!!)?

In the past, the GBD has relied upon “expert opinion” to make such decisions. Well, it seems for the next update of the GBD, which is currently underway, you can also be an expert. I came across a link to the following survey earlier today that allows you to have some input in these weights.

That’s Karen Grepin discussing an attempt to aggregate beliefs over disease burdens to better define the weights given to different ailments. This is a very similar exercise to preference aggregation, where we attempt to construct a unified set of beliefs that will govern public policy. The result is something approaching a social welfare function, which allows us to make statements like “Society strictly prefers A to B.” One way of doing this is to get a sample of individuals to compare different states and to try and tease out an overall ordinal ranking of these states. Using Grepin’s example, each person has to make a pairwise comparison:

The first person has swelling and tenderness in the testicles and pain during urination.

The second person has lost part of both legs, leaving pain, tingling, and frequent sores in the stumps. The person has great difficulty moving around and has episodes of depression, anxiety and flashbacks to the injury.

By asking enough people to compare different states with different combinations of symptoms, we can tease out their overall ranking of those symptoms – how this is done can sometimes be contentious and quite technical. That ranking then represents the best approximation of everyone’s relative rankings of disease burden.

As if we needed any more evidence that centering advocacy and funding around specific diseases was a bad idea, the New York Times reports:

Diarrhea kills 1.5 million young children a year in developing countries — more than AIDS, malaria and measles combined — but only 4 in 10 of those who need the oral rehydration solution that can prevent death for pennies get it.

….lies at the heart of a wider debate over whether the United States and other rich nations spend too much on AIDS, which requires lifelong medications, compared with diarrhea and the other leading killer of children, pneumonia, both of which can be treated inexpensively.

International commitments to combat HIV and AIDS rose at an average annual rate of 48 percent from 1998 to 2007, reaching $7.4 billion and making up almost half of donor financing for global health, according to Professor Shiffman’s analysis of data from the Organization for Economic Cooperation and Development.

For as long as we direct funding vertically towards specific outputs, we’re going to see this sort of imbalance. We need to be investing more in health systems (be they public or private or in-between) that can respond appropriately to needs on the ground and make the optimal allocation decisions that are nigh impossible on a global scale. I have extremely mixed feelings about this quote from the article:

Jeffrey D. Sachs, the Columbia University economist, countered that wealthy donors still spent far too little on global health and rejected what he called the wrong-headed idea that “we need to make a terrible and tragic choice between AIDS or pneumonia.” The United States has invested heavily in the fight against AIDS, and other wealthy nations should pick up more of the cost of other global health priorities, he says.“Rather than tearing down what’s working, we should continue to invest in what’s needed,” he said.

Perhaps it is best that the US sticks to fighting AIDS – life might actually be better if donors bothered to specialise more; this is difficult, as no one wants the unglamorous problems, even if they are the crucial ones. At the same time, think about what Sachs is saying: the components of essential health package that the poor should get should be funded and provided by different groups of people. That’s a recipe for disaster – we should all be putting money into systems instead, not trying to cobble together different health intervention.

Starting next January, whenever you buy an airline ticket at a travel agency or online, there’ll be a new question to answer before you hand over your credit card: Would you be willing to donate $2 to help fight HIV/AIDS, malaria and tuberculosis in Africa?

Would it not make more sense to, oh I don’t know, doing away with the flying in of development workers and consultants on business class tickets, and use the saved money to help fund the health sector?

Sure, there are potentialyl negative incentive effects, but I’m doubtful they are that large. Chris Blattman’s blog had a hugedebate about this a few months ago. Colour me cynical, but I’d be surprised if the money earned from voluntary contributions would come even close to the amount you’d save by cutting back on travel expenses.